Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

chronic rhinosinusitis

1st line – nasal saline irrigation

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ACUTE
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chronic rhinosinusitis
1st line – 

nasal saline irrigation

Initial treatment recommended by American and European guidelines includes nasal saline irrigation.[3][20][21][27][28][29][30][31][32][33]​​​​

Nasal saline irrigations should be used throughout the treatment for both acute and chronic rhinosinusitis. Irrigating debris as well as inflammatory molecules improves secretory stasis and helps to improve nasal congestion and obstruction. Easily performed and usually well tolerated, irrigations have been shown to be safe and beneficial.[28][32][33] A duration of treatment of >8 weeks is recommended.[3]​​

Saline irrigation can be done with a high-volume, high-flow device (e.g., squeeze bottle) two to three times daily to aid in clearance of mucus. Devices with volume of >60 mL have greater benefits.[3]

Plus – intranasal corticosteroid

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ACUTE
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chronic rhinosinusitis
Plus – 

intranasal corticosteroid

Treatment recommended for ALL patients in selected patient group

Initial treatment recommended by American and European guidelines includes topical intranasal corticosteroids.[3][20][21][27][28][29][30][31][32][33]​​​ Corticosteroid nasal irrigations are recommended in postoperative patients and as an option for those undergoing non-surgical therapy.[3]​​

Can be used long term. Safe and effective in chronic rhinosinusitis with and without polyps.[28][29][30][31][32] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ]

Mucosal shrinkage allows for sinus drainage with decrease in overall mucus production.

Risks are very small. Epistaxis is a common complaint.[29][30] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] Patients who have not been instructed in proper use will often spray directly onto the septum. This causes excoriation of the Kiesselbach area (anterior septum) and subsequent nosebleeds. Key to avoidance of bleeds is proper use by directing the spray laterally towards the outside wall of the nose away from the midline septum. Routine nasal hygiene and humidification reduce this risk further.

Systemic absorption is negligible. Rare fungal superinfections occur.

Primary options

budesonide nasal: 32-64 micrograms (1-2 sprays) in each nostril once daily, maximum 256 micrograms/day

OR

fluticasone propionate nasal: 100 micrograms (2 sprays) in each nostril once daily; or 50 micrograms (1 spray) in each nostril twice daily

OR

mometasone nasal: 100 micrograms (2 sprays) in each nostril once daily

OR

triamcinolone nasal: 110 micrograms (2 sprays) in each nostril once daily

OR

flunisolide nasal: 50 micrograms (2 sprays) in each nostril twice daily

Consider – antibiotic therapy

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ACUTE
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chronic rhinosinusitis
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Oral antibiotics may be considered depending on examination/endoscopic findings, and response to initial treatment. If used, antibiotics should ideally be based on cultures.[21]

No antibiotics are US Food and Drug Administration (FDA)-approved for use in chronic rhinosinusitis. The rationale for treatment in chronic rhinosinusitis is to eradicate bacterial infection. Antibiotics are also used in the short-term for acute exacerbations, with a treatment duration shorter than 4 weeks.[21] Longer term antibiotics (≥4 weeks) may be considered if nasal saline irrigation and topical intranasal corticosteroids have not led to an improvement in symptoms after 3 months, particularly if the patient’s main complaint is discharge/facial pain.[27] 

Prolonged antibiotics may be utilised in patients with persistent purulence, but the evidence is not very strong and this is not common in practice.[21] One systematic review recommended a short (<3 weeks) course of antibiotics as a treatment option, except for macrolides, for which there is evidence of effectiveness for longer courses in selected patients.[34] One Cochrane review found moderate-quality evidence of a modest improvement in disease‐specific quality of life in adults with chronic rhinosinusitis, without polyps, who had received three months of a macrolide antibiotic.[35]

Risks include allergic reaction and development of antibiotic resistance. Regional drug susceptibility patterns should be considered.

Culture-directed antibiotic therapy (based on endoscopically obtained samples from the middle meatus) is recommended for patients with infection refractory to initial antibiotic treatment.

The FDA has issued a safety warning stating that serious side effects associated with fluoroquinolones outweigh the benefits for patients with rhinosinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options.[36] The FDA advises that for patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.

Primary options

amoxicillin/clavulanate: chronic: 250 mg orally three times daily for 3-4 weeks; or 500 mg orally twice daily for 3-4 weeks; acute exacerbations: 500 mg three times daily for 10 days; or 875 mg twice daily for 10 days

More

OR

cefuroxime: 250-500 mg orally twice daily for at least 10 days

OR

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily for 20 days

Secondary options

clarithromycin: 250-500 mg orally (immediate-release) twice daily for 10 days or preferably 3-4 weeks

OR

clindamycin: 300 mg orally four times daily for at least 10 days

More

OR

levofloxacin: chronic: 500 mg orally once daily for 3-4 weeks; acute exacerbations: 750 mg orally once daily for 5 days

More

Consider – decongestant

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ACUTE
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chronic rhinosinusitis
Consider – 

decongestant

Additional treatment recommended for SOME patients in selected patient group

Decongestants can be used for symptomatic relief. They help to reduce tissue oedema, facilitate drainage, and promote patency of sinus ostia.

Available in topical and oral forms, each differing slightly in its method of action. Topical agents provide almost immediate symptomatic relief by shrinking inflamed and swollen nasal mucosa. Topical nasal formulations should not be used for longer than 3-5 consecutive days because of the risk of tolerance, rhinitis medicamentosa, and rebound after drug withdrawal.

Oral systemic agents are used when decongestion is necessary for >3 days. They are alpha-adrenergic agonists that reduce nasal blood flow.

The sympathomimetic decongestant pseudoephedrine can be considered a secondary option. However, pseudoephedrine-containing medications are associated with a risk of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome. These are rare conditions with potentially serious and life-threatening complications.

Pseudoephedrine-containing medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[46]

Primary options

oxymetazoline nasal: (0.05%) 2-3 sprays in each nostril twice daily, maximum 6 sprays/day

OR

phenylephrine nasal: (0.25 to 1%) 1-2 drops/sprays in each nostril every 4 hours when required

Secondary options

pseudoephedrine: 60 mg orally (immediate-release) every 6 hours when required; or 120 mg orally (extended-release) every 12 hours when required; maximum 240 mg/day

Consider – antihistamine or leukotriene receptor antagonist

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ACUTE
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chronic rhinosinusitis
|
concomitant allergic rhinitis
Consider – 

antihistamine or leukotriene receptor antagonist

Additional treatment recommended for SOME patients in selected patient group

Antihistamines can be used selectively if there is an apparent allergic component to sinus symptoms (e.g., sneezing, itchy eyes, and rhinorrhoea), which are often seasonal. Empirical treatment with oral antihistamine can be attempted initially. Some patients prefer direct treatment via topical intranasal antihistamine. Patients who do not improve may be candidates for allergy testing.

Leukotriene receptor antagonists can be used as second line. They inhibit the leukotriene pathway involved with inflammation. Initially developed for patients with asthma, they have been advocated for patients with asthma, allergic rhinitis, and/or chronic rhinosinusitis.[32][37]

The US Food and Drug Administration (FDA) has strengthened its warning for montelukast (a leukotriene receptor antagonist) about serious behaviour- and mood-related changes. For allergic rhinitis, the FDA has determined that montelukast should be reserved for those who are not treated effectively with, or cannot tolerate, other allergy medicines.[38]

Primary options

loratadine: 10 mg orally once daily when required

OR

fexofenadine: 60 mg orally every 12 hours when required; or 180 mg orally once daily when required

OR

desloratadine: 5 mg orally once daily when required

OR

chlorphenamine: 4 mg orally (immediate-release) every 4-6 hours when required, maximum 24 mg/day

OR

azelastine nasal: 2 sprays in each nostril every 12 hours when required

OR

cetirizine: 5-10 mg/day orally given as a single dose or in 2 divided doses when required

Secondary options

zafirlukast: 20 mg orally twice daily

OR

montelukast: 10 mg orally once daily

OR

zileuton: 1200 mg orally (extended-release) twice daily

ONGOING

continued symptoms despite medical therapy

1st line – endoscopic sinus surgery

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ONGOING
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continued symptoms despite medical therapy
1st line – 

endoscopic sinus surgery

Significantly symptomatic patients failing medical therapy, with sinus inflammation on post-therapy computed tomography (CT) are considered surgical candidates. For patients with extensive disease, previous surgery, or need for surgery in anatomically sensitive areas (e.g., frontal or sphenoid sinuses), image-guided surgery is advocated. The CT scan is downloaded onto a computer and the patient's head is matched to CT scan coordinates pre-operatively.[Figure caption and citation for the preceding image starts]: Pre-op planning at a surgical navigation workstationFrom the personal collection of Dr Raj Sindwani; used with permission [Citation ends].com.bmj.content.model.Caption@6c120b63 The system tracks the tips of surgical instruments in the sinuses and the patient's head using infrared/electromagnetic technology.[Figure caption and citation for the preceding image starts]: Image-guided endoscopic sinus surgery using an optical-based surgical navigation systemFrom the personal collection of Dr Raj Sindwani; used with permission [Citation ends].com.bmj.content.model.Caption@369bd738 Complications of sinus surgery include bleeding, infection, brain injury/cerebrospinal fluid leak, orbital injury (bruising, double vision/blindness), residual/recurrent sinus disease, and the need for revision surgery. Major complications (intracranial and orbital) are very rare (<1%).[37][41] When counselling patients before surgery, it is important to note that nasal obstruction improves the most, facial pain and discharge improve moderately, while headache and hyposmia improve least.[43] Fatigue and body pain also improve after endoscopic sinus surgery.[44][45]

Consider – oral corticosteroid

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ONGOING
|
continued symptoms despite medical therapy
Consider – 

oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Used in preparation for surgery and in acute exacerbations.[27]

Primary options

methylprednisolone: 24 mg orally on day one, decrease by 4 mg/day increments each day for 5 days

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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